Account Of Case Mix Research Articles

Case-Mix Accounting System Design in Social and Health Care Sector - The Mechanisms of Hybridization

Case-Mix Accounting System Design in Social and Health Care Sector - The Mechanisms of Hybridization

DRG-based payment system and management accounting changes in an Indonesian public hospital: exploring potential roles of big data analytics

PurposeThis study aims to provide insights into management accounting changes (MACs) and potential roles of big data analytics (BDA) in accelerating the MACs in an Indonesian public hospital as a response towards the adoption of the diagnosis-related groups (DRG)-based payment system.Design/methodology/approachA mixed-method approach was used to collect and analyse data from a referral public hospital in Indonesia. First, a BDA simulation was carried out to reveal its usefulness in predicting and evaluating patient costs, and finally improving the cost recovery rate (CRR) of each DRG case. This part formulated and tested the mathematical models that predict patient cost, the CRR and determinants (length of stay/LOS, severity/SEV, patient age/AGE and gender/SEX). For this purpose, data of the top ten inpatient cases of 2018 were collected and analysed. Second, semi-structured interviews with senior staff and doctors were carried out to understand cost control strategies implemented in the hospital and the management and doctors’ perceptions regarding the application of tested mathematical models for cost control. Old institutional economics and new institutional sociology were used to gain insight about how and why management accounting practices changed in the hospital.FindingsThe findings show that the absence of detailed per-case/patient cost information has not only hindered further evolvement of MACs but also stimulate tensions between managerial and medical worlds in the studied Indonesian public hospital. The simulation of BDA in this study was not only discovering the determinants of case cost recovery but also enabling the prediction of CRR of patients immediately after admission. The application of BDA and casemix accounting in the hospital will potentially become catalysts of discussion and mutual learning between managerial and medical staff in controlling patient costs.Originality/valueThis paper provides a more comprehensive picture of the potential roles of BDA in cost control practices. The study assesses the feasibility of BDA application in the hospital and evaluates the potential roles and acceptance of BDA application by both management and doctors.

Case-mix accounting beyond the hospital

Purpose This paper aims to examine how the customer can be better integrated into case-mix systems for primary healthcare. Case-mix is an established performance management tool in hospitals, and there is growing interest in its extensions into out-of-hospital healthcare. Design/methodology/approach Interviews with academics and clinicians are used to explore conceptual foundations for this area. A service-dominant logic perspective is used to problematize the roles of accounting in this complex setting. Findings The findings identify that a customer focus is embedded in current primary healthcare thinking, contrasting with the goods-dominant focus in hospitals. This paper identifies diverse objectives and coordinating networks of care as challenges for case-mix. Research limitations/implications This paper breaks down the complexity of primary healthcare case-mix into two accounting roles: a “dialogue machine” to understand client objectives and a “learning machine” to understand clients’ networks of resources. The infancy of case-mix for primary healthcare means our interview sample is restricted to a small group of pioneers in the area, within a supply perspective. Practical implications Primary healthcare management is a priority area in New Zealand. The findings describe opportunities and challenges for the “dialogue” and “learning” roles of accounting. This paper discusses practical and ideological tensions to be resolved when integrating customers into case-mix systems. Originality/value This paper contributes to the limited literature on the use of case-mix accounting outside of hospitals, discussing the role of customers and networks of care. Findings contribute by describing the customer as both a source of, and a means to resolving, complexity.

Hypertension and intra‐operative incidents: a multicentre study of 125 000 surgical procedures in Swiss hospitals*

It is debated whether chronic hypertension increases the risk of cardiovascular incidents during anaesthesia. We studied all elective surgical operations performed in adults under general or regional anaesthesia between 2000 and 2004, in 24 hospitals collecting computerised clinical data on all anaesthetics since 1996. The focus was on cardiovascular incidents, though other anaesthesia-related incidents were also evaluated. Among 124,939 interventions, 27,881 (22%) were performed in hypertensive patients. At least one cardiovascular incident occurred in 7549 interventions (6% (95% CI 5.9-6.2%)). The average adjusted odds ratio of cardiovascular risk for chronic hypertension was 1.38 (95% CI 1.27-1.49). However, across hospitals, adjusted odd ratios varied from 0.41 up to 2.25. Hypertension did not increase the risk of other incidents. Hypertensive patients are still at risk of intra-operative cardiovascular incidents, while risk heterogeneity across hospitals, despite taking account of casemix and hospital characteristics, suggests variations in anaesthetic practices.

Unplanned General Surgical Re-Admissions – How Many, Which Patients and Why?

The unplanned re-admission rate is a national key performance indicator employed by the UK Department of Health. An adjusted figure, based on admission information data on the hospital electronic Patient Administration System (PAS), but adjusted to take account of case mix is compared with a calculated 'expected'. While previous studies have investigated unplanned re-admission rates in age-, procedure- or process-specific conditions, 'all-cause' general surgical re-admission rate is yet to be studied. The aim of this study was to assess the accuracy of hospital unplanned re-admission data, and identify patterns or possible causes of unplanned general surgical re-admissions. Retrospective audit of case note records of all patients identified from the hospital electronic PAS as unplanned, general surgical re-admissions over a period of 4 consecutive months. Of all 161 re-admissions in this study, 46 (29%) were unrelated to the index admission, planned or involved patient self-discharge during the index admission. Of the 'genuine', unplanned re-admissions, 80 (78%) followed an emergency index admission, 58 (56%) had chronic or recurrent symptoms, for which 26 (25%) were on waiting lists. Fourteen (14%) were multiple admissions of 4 patients, while 8 (8%) re-admissions required further surgery for significant postoperative complications. Unplanned. general surgical re-admission rates collated from hospital PAS systems may be inaccurate. Nearly half of 'genuine', unplanned re-admissions involved patients with chronic and/or recurrent symptoms, which are predictable and may be preventable. Significant postoperative complications accounted for few re-admissions in this study.

Survival after liver transplantation in the United Kingdom and Ireland compared with the United States

Background and objective:Surgical mortality in the US is widely perceived to be superior to that in the UK. However, previous comparisons of surgical outcome in the two countries have often...

DRG-based prospective pricing and case-mix accounting—Exploring the mechanisms of successful implementation

Escalating health care expenditures have brought on the need for restructuring health care delivery. A common response to this problem has been to seek market-based solutions. In the literature, however, increasing concern has been expressed that hospital management reforms will fail or will have only a limited impact. This longitudinal case study extends our understanding of the effects of implementing DRG-based prospective pricing and case-mix accounting systems for hospital management control in a specific health care setting. Moreover, this study contributes to current knowledge by focusing on the mechanisms explaining successful implementation of new accounting and control systems in the health care sector. A deep understanding of these mechanisms may help us to design better management control systems, and thus circumvent problems in implementing these systems. Our study suggests that successful implementation in the studied context is strongly dependent on the involvement of clinicians in this process. Integrated clinical and financial accountability, assigning responsibility for implementation to clinicians, freedom in choosing appropriate control tools, and flexibility in adoption all facilitated implementation. Furthermore, we argue that this process has also been advanced by the gradual implementation of these reforms and intensifying institutional pressures.

Assessing Mortality Rates from Dubious Data—When to Stop Doing Statistics and Start Doing Mathematics

When trying to assess surgical outcomes at a particular centre, it is important to take account of case mix in terms of the types of operation performed. This is because those centres that undertake a disproportionately high number of complex operations might well be expected to have higher mortality rates than other centres whose case mix is more routine. From a statistical viewpoint, such case-mix adjustment is relatively straightforward if there are reliable risk estimates for different operation types. However this may not be the case and the risk estimates may have to be derived from several different sources which may not themselves be in agreement. Here, standard case-mix adjustment methods are no longer applicable and alternative analysis methods need to be used to make use of such unreliable risk estimates.

Accounting information systems as knowledge-objects: some effects of objectualization

This paper will outline a research methodology informed by theorists who have contributed to actor network theory (ANT). Research informed from such a perspective recognizes the constitutive role of accounting systems in the achievement of broader social goals. Latour, Knoor Cetina and others argue that the bringing in of non-human actants, through the growth of technology and science, has added immeasurably to the complexity of modern society. The paper ‘sees’ accounting and accounting systems as being constituted by technological ‘black boxes’ and seeks to discuss two questions. One concerns the processes which surround the establishment of ‘facts’, i.e. how ‘black boxes’ are created or accepted (even if temporarily) within society. The second concerns the role of existing ‘black boxes’ within society and organizations. Accounting systems not only promote a particular view of the activities of an organization or a subunit, but in their very implementation and operation ‘mobilize’ other organizational members in a particular direction. The implications of such an interpretation are explored in this paper. Firstly through a discussion of some of the theoretic constructs that have been proposed to frame ANT research. Secondly an attempt is made to relate some of these ideas to aspects of the empirics in a qualitative case study. The case site is in the health sector and involves the implementation of a casemix accounting system. Evidence from the case research is used to exemplify aspects of the theoretical constructs.

Casemix accounting systems and medical coding

The adoption of DRG coding may be seen as a central feature of the mechanisms of the health reforms in New Zealand. This paper presents a story of the use of DRG coding by describing the experience of one major health provider. The conventional literature portrays casemix accounting and medical coding systems as rational techniques for the collection and provision of information for management and contracting decisions/negotiations. Presents a different perspective on the implications and effects of the adoption of DRG technology, in particular the part played by DRG coding technology as a part of a casemix system is explicated from an actor network theory perspective. Medical coding and the DRG methodology will be argued to represent “black boxes”. Such technological “knowledge objects” provide strong points in the networks which are so important to the processes of change in contemporary organisations.

ACCOUNTING IN HEALTH CARE: SOME EVIDENCE ON THE IMPACT OF CASEMIX SYSTEMS

This paper reports on an in-depth study of the implementation of a sophisticated system of casemix budgeting within a large public hospital located in the central North Island, New Zealand. This hospital is the main institution within the Waikato Crown Health Enterprise. Research consisted of site visits over a two year period. Intensive research methods were employed.It has been argued that accounting systems provide a rationalistic image of organization practice and operation to external observers. This literature tends to portray accounting systems as decoupled from the internal operations of the organization. Accounting is argued to be a key technique in mediating the environment between the organization and its external constituents. In contrast, this paper reports changes in working practices and clinical procedures as a consequence of the use of both DRG coding and the processes which have been put in place to facilitate casemix accounting. Evidence is presented of the influence of casemix information on professional work patterns, work relationships and in management structures. It is argued that these changes have more or less direct effects on resource allocations.

Casemix accounting systems: new spaces for action

This paper discusses the implementation of a casemix accounting system within a large New Zealand public hospital. In the context of healthcare, casemix accounting systems are involved in attempts to increase the cost-consciousness of clinicians through the rationalization and codification of clinical activity. The paper considers the power effects of casemix accounting using a perspective that views such information and control systems as disciplinary technologies. The complex and contradictory setting of the hospital characterized by a negotiated order meant that while the casemix accounting system did appear to provide some controlling influence, it also produced forms of resistance on the part of clinicians. Our experience suggests that such systems are best thought of as making possible a new discursive space within which all organizational participants, in this case both management and clinicians, can act.

Monitoring the performance of cardiac surgeons

In the past, simple methods have been used to examine the performance of surgeons by examining the cumulative in-hospital mortality of their patients, without regard to the severity of the cases involved. This paper describes an alternative approach which takes account of an individual cardiac surgeon's case-mix by explicitly incorporating the inherent risk faced by patients due to a combination of factors relating to their age and the degree of disease they have.

The changing power equation in hospitals.

This research traces the origins, development, and reasons for change in the power equation in the U.S. hospitals between physicians, administrators and accountants. The paper contains three major sections: a review of the literature concerning authority, power, influence, and institutional theory; a review of the development of the power of professions, especially physicians, accounting and healthcare administrators, and the power equilibrium of a hospital; and, a discussion of the social policy implications of the power struggle. The basis for physicians' power derives from their legal ability to act on which others are dependent, such as choosing which hospital to admit patients, order tests and procedures for their patients. The Federal Government's prospective payment system and the hospitals' related case-mix accounting systems appear to influence the power structure in hospitals by redistributing that power. The basis of the accountants' power base is control of financial information. Accountants have a definite potential for influencing which departments receive financial resources and for what purpose. This moves hospital accountants into the power equation. The basis of the hospital administrators' power is their formal authority in the organization. Regardless of what actions federal government agencies, hospital accountants, or hospital administrators take, physicians are expected to remain the dominant factor in the power equation. Without major environmental changes to gain control of physician services, only insignificant results in cost containment will occur.

An institutional theory perspective on the DRG framework, case-mix accounting systems and health-care organizations

Case-mix accounting systems have been advanced as both reflecting the economic reality that underlies a hospital's various “product lines”, as defined by DRG prospective payment categories, and facilitating rational decision making regarding resource acquisition, deployment and use. This article uses the institutional perspective to extend this conceptualization of case-mix accounting systems. The institutional perspective proposes that many elements of organizational structure, like case-mix accounting systems, reflect as much a need to conform to societal expectations of acceptable practice as the technical imperative of fostering rationality. This article also extends institutional theory regarding the issues of power and decoupling by considering institutionalization to be an unfinished process in the health-care context, wherein the active agency of individuals and organizations is subjected to systematic examination. In this specific context, case-mix accounting may play a significant role in establishing and perpetuating — not merely supporting — the very social structure of legitimacy, and may consequently be considered an interest-oriented activity having the potential to penetrate and alter the internal operating processes of financially strained hospitals.

Case Mix Accounting in Hospital Budgeting, Cost Control and Prospective Reimbursement

Case Mix Accounting in Hospital Budgeting, Cost Control and Prospective Reimbursement